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284-43-4000  <<  284-43-4020 >>   284-43-4040

PDFWAC 284-43-4020

Grievance and complaint procedures—Generally.

(1) Each carrier must adopt and implement a comprehensive process for the resolution of appeals of adverse determinations. This process shall meet accepted national certification standards such as those used by the National Committee for Quality Assurance except as otherwise required by this chapter.
(2) This process must conform to the provisions of this chapter and each carrier must:
(a) Provide a clear explanation of the appeal process upon request, upon enrollment to new enrollees, and annually to enrollees and subcontractors of the carrier.
(b) Ensure that the appeal process is accessible to enrollees who are limited-English speakers, who have literacy problems, or who have physical or mental disabilities that impede their ability to file an appeal.
(c) Implement procedures for registering and responding to oral and written appeals in a timely and thorough manner including the notification of an enrollee that an appeal has been received.
(d) Assist the enrollee with all appeal processes.
(e) Cooperate with any representative authorized in writing by the enrollee.
(f) Consider all information submitted by the enrollee or representative.
(g) Investigate and resolve all appeals.
(h) Provide information on the enrollee's right to obtain second opinions.
(i) Track each appeal until final resolution; maintain, and make accessible to the commissioner for a period of three years, a written log of all appeals; and identify and evaluate trends in appeals. The written log may be maintained electronically.
[WSR 16-01-081, recodified as § 284-43-4020, filed 12/14/15, effective 12/14/15. Statutory Authority: RCW 48.02.060, 48.43.525, 48.43.530, 48.43.535, and The Patient Protection and Affordable Care Act, P.L. 111-148, as amended (2010). WSR 12-23-005 (Matter No. R 2011-11), § 284-43-615, filed 11/7/12, effective 11/20/12. Statutory Authority: RCW 48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.30.010, 48.44.050, 48.46.100, 48.46.200, 48.43.505, 48.43.510, 48.43.515, 48.43.520, 48.43.525, 48.43.530, 48.43.535. WSR 01-03-033 (Matter No. R 2000-02), § 284-43-615, filed 1/9/01, effective 7/1/01.]
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